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THE DUTCHESS COUNTY PROJECT AFTER FIVE YEARS HERMAN B. SNOW In this paper I want to stress the role of administrative decisions and functions. I feel that the role administration plays has been par­ tially overlooked and not given enough stress. The decisions which are made can affect the clinical aspect of the program directly, for better or worse. While most of my comments deal with the Dutchess County Project, I will also make comparisons with other units that I know. When Dr. Harry Solomon gave his presidential address to the American Psychiatric Association in 1958,1 he brought into prominence the large mental hospitals which, he felt, contributed to prolonged hospitalization and increasing mental disability. He started an increasing controversy of the large versus the small hospital and the community mental health units. Since his address there has been a scramble toward the ever-elusive millenium, the search for the magic combination of fac­ tors that would do away with the large hospital and its chronic residual population, and at the same time treat arriving patients in a setting that would prevent any long-term illness. Suddenly there appeared on the scene many facilities and plans, each with its own philosophy for the combination of opening the locks on the gates to Utopia. The planners seemed to take it for granted that the large hospital was detrimental to the patient, without really having any evidence that it was so, or that the small hospital would in any way be better. Size in itself seemed to be emphasized when in reality it was not the size but the type of personnel and the program for the patient which were important. 57 Most people, in their honest zeal to reach the goal, developed a rigid philosophy and a unifocal vision. They were so inflexible as to leave no room for detours into new ideas or for new experiences, or to con­ sider the possible value of other projects. For the purposes of orientation to the New York State Department of Mental Hygiene and the Hudson River State Hospital, I should like to make the following comments. I hope these comments will ultimately clarify for you the position of the Dutchess County Unit. In this state, the Commissioner of Mental Hygiene is a cabinet officer. He is appointed by the Governor and works directly under the Governor. The commissioner has two deputy commissioners, one of whom is in charge of program administration while the other is in charge of professional standards and services. These two deputy commissioners have a number of assistant and associate commissioners under them who are in charge of various divisions such as the hospitals, institutions for the mentally retarded, community services, forensic psychiatry, and the various ancillary services such as occupational therapy, recreational therapy, and other programs. The commis­ sioner also has an administrative and fiscal manager who is his busi­ ness adviser as well as the person in charge of all the financial dealings of the department. The purchases for all of the institutions in the department are made, for the most part, through the central office where everything has to be approved and then is further approved by the division of stan­ dards and purchases and the budget division. It takes approximately one-third of the New York State budget to support the Department of Mental Hygiene. We work on a line item budget with some leeway allowed, depending on the occasion. Through a great deal of study over the years, the central office has arrived at a certain number of factors which are relatively stationary from one year to another, for example, the cost of food per patient, or the amount of clothing per patient, or the amount of maintenance and upkeep in a general way. Over the years a program for personnel has also been developed, so that a table of organization applies to the whole department and a director of one institution does not have more than another. There is a patient-nursing service personnel ratio for a reception service, or a geriatric service, or a continued treatment service. All of these figures are calculated to arrive at a suitable number of personnel in the nursing service. If the population of a hospital should drop, there would be certain adjustments, with personnel taken away gradually. 58 If the population increases in a hospital, there are adjustments at a certain time and an increase in personnel will be made. There are similar formulas for occupational and recreational therapists, social workers, etc. The appropriation of the budget for new equipment is generally divided into new equipment, replacement equipment, and capital projects. How much each hospital receives depends on the amount of money available at a given time. Generally speaking, projects, new equipment, and replacements are carefully scrutinized all along the line and, for the most part, the hospitals get most of the necessary items. There are 20 state hospitals in New York State, caring for approximately 84,000 patients; six state schools serve approximately 23,000 patients, and one institution for epileptics has a population of about 2,000. These are resident patients and do not include those on convalescent and family care. All the hospitals are organized in about the same way. There is the director, who is the head of the institution. He has an associate director and several assistant directors to aid him. The number de­ pends on the size of the hospital. At the Hudson River State Hospital we have five assistant directors, three of whom do clinical work and two of whom do administrative work; their positions and duties are interchangeable at any time. On the next level are the supervising > psychiatrists; these doctors are in charge of services or important ; projects and are assisted by the senior psychiatrists and residents. ; There are 4,600 resident patients at the Hudson River State Hos- : pital. To take care of them, we have 50 doctors, 1,200 nursing service personnel, and about 800 other personnel, including all of the ancillary services, business office, and general maintenance personnel. The Hudson River State Hospital is the sixth largest hospital in the state, and it costs approximately 12 million dollars a year to run it. About 10 years ago, there were 6,800 resident patients; about four years ago this dropped to 5,800 patients, and in the past three years the figure has dropped to 4,600. The hospital was established in 1890, when most of the buildings were erected. Since then several modem l buildings have been constructed so that you see both old and modern ' types of architecture as you go through the grounds. The building j opposite the Dutchess County Unit is called the Cheney Memorial % Building. It has a capacity of 1,000 patients. Each ward has between i 30 and 40 beds, with small dormitories and many private rooms. There • are 450 geriatric patients in the building and a complete reception 59 service for about 250 patients. It has two admission wards where pa­ tients are admitted, studied, started on their treatments, and then transferred to the reception ward where they will stay until they are well enough to go home, or, if the prognosis after several months in the reception center still appears poor, they will be transferred to another part of the hospital. Patients are kept in the reception center as long as possible since we have found that the farther they get from this center, the longer it will take them to get home. This huge build­ ing also has an operating room and a complete medical service. There is a school of nursing, a pharmacy, and a complete clinical setup for every medical specialty, a dental department, an x-ray unit, physio­ therapy, occupational therapy divisions, recreation rooms, beauty par­ lors, and the research unit which is associated with Dr. Gruenberg. ORGANIZATION At the end of 1959, plans were made to start a geographically de­ centralized unit in Dutchess County, New York State. This was to function as independently as possible from the Hudson River State Hospital, the parent organization. There were many reasons why the New York State Department of Mental Hygiene and the Milbank Memorial Fund finally decided on Dutchess County. It has a popula­ tion of approximately 190,000. It has the highest or the next to highest admission rate for any county in New York State, approxi­ mately 375 patients per 100,000 population being admitted in the past several years; it also has the dubious distinction of having nearly the highest percentage of emergency health officer certificates issued for patients’ admission. The county government had a good mental health board and an active mental health society and a good community men­ tal health clinic. The relationship of the Hudson River State Hospital to the community was a good one. In retrospect, it is necessary to point out mistakes that were made so that others could consider them and, hopefully, not make the same mistakes again. The criticisms are not a reflection on the original planners. The criticism merely shows that a program must be elastic and must change as local conditions warrant, and that a rigid, unifocal philosophy in a small unit can be detrimental. The first step in the original plan put into effect in 1960 was to set aside two buildings which housed 517 patients. Almost all of the patients who had ever come from Dutchess County were then trans- 60 ferred to this unit. Only 80 beds were left for newly admitted patients. With an admission rate of approximately 50 a month, the bed vacancies disappeared and the unit became “choked/5 so to speak.

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